CMS-10401-3Rs Supporting_Statement_Revised

Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

A. Background
The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23,
2010, and the Health Care and Education Reconciliation Act, Public Law 111-152, enacted on
March 30, 2010 (collectively, the “Affordable Care Act”), provides for three premium stabilization
programs – a reinsurance program, a risk corridors program, and a risk adjustment program – to
mitigate the negative impacts of adverse selection and market uncertainty. On March 23, 2012,
The Centers for Medicare & Medicaid Services (CMS) published the Premium Stabilization Rule
(77 FR 17220) to implement and set standards for these premium stabilization programs. CMS
also published a proposed Notice of Benefit and Payment Parameters for 2014 (“draft Notice”) to
implement sections 1311, 1341, 1342, 1343, 1401, 1402, 1411, and 1412 of the Affordable Care
Act, as well as to expand on standards set forth in the Premium Stabilization Rule. On March 11,
2013, CMS published the final Notice of Benefit and Payment Parameters for 2014 (“final
Payment Notice.”)
The transitional reinsurance program and the temporary risk corridors program are designed to
provide issuers with greater payment stability as insurance market reforms begin. The reinsurance
program serves to reduce the uncertainty of insurance risk in the individual market in each State by
making payments for high-cost enrollees. The HHS-administered risk corridors program serves to
protect against rate-setting uncertainty with respect to qualified health plans by limiting the extent
of issuer losses (and gains). The permanent risk adjustment program is intended to protect health
insurance issuers that attract a disproportionate number of higher risk enrollees (e.g., those with
chronic conditions). These programs will support the effective functioning of the American
Health Benefit Exchanges (“Exchanges”), which will become operational by January 1, 2014. The
Exchanges are individual and small group health insurance marketplaces designed to enhance
competition in the health insurance market and to expand access to affordable health insurance for
millions of Americans. The reporting and data collection provisions described below apply to
States and health plans both inside and outside of an Exchange.
B. Justification
1.

Need and Legal Basis

Section 1341 of the Affordable Care Act provides that each State must establish a transitional
reinsurance program to help stabilize premiums for coverage in the individual market during the
first three years of Exchange operation. Section 1342 provides for the establishment of a
temporary risk corridors program that will apply to qualified health plans in the individual and
small group markets for the first three years of Exchange operation. Section 1343 provides for a
program of risk adjustment for all non-grandfathered plans in the individual and small group
market both inside and outside of the Exchange. These risk-spreading programs, which will be
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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

implemented by HHS and/or States, are designed to mitigate adverse selection and provide
stability for health insurance issuers in the individual and small group markets as market reforms
and Exchanges are implemented.
Section 1321(a) also provides broad authority for the Secretary to establish standards and
regulations to implement the statutory requirements related to Exchanges, reinsurance, risk
adjustment, and other components of title I of the Affordable Care Act.

2.

Information Users

The data collection and reporting requirements described below will enable States and/or
HHS to implement these programs, which will mitigate the impact of adverse selection in the
individual and small group markets both inside and outside the Exchange.
3.

Use of Information Technology

Information collected for this rule will be submitted electronically. HHS staff will
communicate with States and the District of Columbia using standardized reporting, e-mail or
telephone.
4.

Duplication of Efforts
This information collection does not duplicate any other Federal effort.

5.

Small Businesses
This information collection will not have a significant impact on small businesses.

6.

Less Frequent Collection

The anticipated flows of funds for these programs require the collection of information as
indicated. A less frequent collection could result in cash flow difficulties for issuers and logistical
difficulties for issuers and the entities operating premium stabilization programs.
7.

Special Circumstances

In order for payments to be made in a timely manner for these premium stabilization
programs, it is necessary to collect information according to timeframes established by the State or
HHS on behalf of the State.
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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

8.

Federal Register/Outside Consultation

CMS provided 60-day notice for this information collection in the Federal Register published
as part of the proposed Notice of Benefit and Payment Parameters for 2014 (77 FR 73117). We
have considered and responded to comments received in response to that information collection
notice as part of the final Notice of Benefit and Payment Parameters for 2014 (78 FR 15410), and
have revised this supporting statement to reflect our response to those comments. We have
additionally consulted with contractors, academia, States, and industry on the feasibility of this
information collection, and have based many of the requirements in this information collection on
those consultations.
9.

Payments/Gifts to Respondents
No payments or gifts will be provided to respondents.

10. Confidentiality
We will maintain respondent privacy with respect to the information collected to the extent
required by applicable law and HHS policies.
11. Sensitive Questions
There are no sensitive questions included in this information collection effort.
12. Burden Estimates (Hours & Wages)
Below is a summary of the information collection requirements set forth in the final rule.
Throughout this summary, the frequency of data collection is assumed to be the frequency
discussed in the preamble to the rule.
A number of assumptions are made regarding the wages of personnel needed to accomplish the
proposed collection of information. Wage rates are based on the Employer Costs for Employee
Compensation report by U.S Bureau of Labor Statistics and represent a national average. Some
States or employers may face higher or lower wage burdens. Wage rates estimates include a 35%
fringe benefit estimate for State employees and a 30% fringe benefit estimate for private sector
employees. We present an annualized estimate of the burden associated with these information
collection requirements below.

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

I. Health Insurance Issuer Standards Related to the Transitional Reinsurance Program
(§153.400-§153.420)
Within Part 153, subpart E we discussed reporting requirements for health insurance issuers
related to the transitional reinsurance program. Based on data from the healthcare.gov website, we
estimate there are approximately 1,800 issuers in the individual and small group markets. Based on
2012 data from the Department of Labor, we estimate that 22,900 entities (including self-insured
and partially insured entities) will make reinsurance contributions.
Calculation of Reinsurance Contributions (§153.405)
As described in §153.400(b) all contributing entities both inside and outside of the
Exchange will be required to provide enrollment data (covered lives and member months) to the
applicable reinsurance entity or the Federal reinsurance contributions entity to substantiate
contribution amounts. As described in §153.405, we propose requiring contributing entities to
provide annual counts of their enrollment and reinsurance contributions to HHS based on their last
reported Patient-Centered Outcome Trust Fund (PCORTF) number as modified for reinsurance
purposes. The burden associated with this requirement is the time and effort required by an issuer
or self-insured group health plan to derive an annual enrollment count. Because issuers and selfinsured group health plans will already be under an obligation to determine a count of covered
lives using a PCORTF method, the burden associated with this requirement is the additional
burden of conducting these counts using the slightly modified counting methods specified in the
final Payment Notice. On average, we estimate it will take each issuer 1 hour to reconcile and
submit final enrollment counts to HHS. Assuming an hourly wage rate of $55 for an operations
analyst, we estimate an aggregate burden of $1,259,500 for 22,900 reinsurance contributing
entities subject to this requirement.
Request for Reinsurance Payments (§153.410)
As described in §153.410(a), health insurance issuers of reinsurance-eligible plans seeking
reinsurance payment must make a request for payment in accordance with the requirements in the
HHS notice of benefit and payment parameters or the State notice of benefit and payment
parameters, as applicable. To the greatest extent possible, we wish to minimize burden for issuers.
The data collected, and the manner in which that data will be collected, will be identical for both
the reinsurance and risk adjustment programs. HHS has determined that issuers will need to
maintain data elements identified in Appendix A in order to make reinsurance payment requests. A
subset of issuers (specifically, issuers operating reinsurance-eligible plans in the individual
market) subject to the risk adjustment data collection requirements are eligible to make
reinsurance payment requests. As such, we anticipate minimal burden associated with this
provision; the burden associated with this provision is described in Part III of this section.
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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

As described in §153.420(a), to be eligible for reinsurance payments, an issuer must submit or
make accessible all required reinsurance data in accordance with the reinsurance data collection
approach established by the State or HHS on behalf of the State. As described in 153.420(b) the
submission deadline is April 30 of the year following the applicable benefit year.
II. Health Insurance Issuer Standards Related to the Temporary Risk Corridors
Program (§153.520-§153.530)
Within Part 153, subpart F we discussed reporting and recordkeeping requirements for QHP
issuers related to the risk corridors program. As described in §153.520(e), QHP issuers will be
required to maintain data and supporting information used to make the required allocations and
attributions of revenues and expenses, and to determine that the methods and bases detailed in the
report described below were accurately implemented. As described in §153.520(c), we will
require all QHP issuers to submit to HHS a detailed description of the methods and specific bases
used to attribute revenues and expenses in allowable costs and target amount to each QHP and
across plans. Under §153.530, we will also require all QHP issuers to submit data on premiums
earned, allowable costs, and allowable administrative costs. While these information collection
requirements are subject to the Paperwork Reduction Act, the associated requirements and
instruments are currently under development. Upon their completion, we will seek OMB approval
and solicit public comments.
III. Health Insurance Issuer Standards for the Risk Adjustment Program (§153.610§153.630; and §153.700-730)
Within Part 153, subpart G, we described reporting requirements for health insurance
issuers related to the risk adjustment program.
As described in §153.610, health insurance issuers will be required to maintain risk
adjustment data in order for HHS to operate risk adjustment on behalf of the State. HHS has
determined that issuers will need to maintain data elements identified in Appendix A. HHS intends
to employ a distributed data approach when running risk adjustment on behalf of a State and will
also use this data for the purpose of determining the risk adjustment user fee for each issuer.
Under §153.610(f), we establish a user fee to support Federal operation of risk adjustment.
This per capita monthly fee will be charged to issuers of risk adjustment covered plans based on
enrollment estimates provided to HHS in the distributed data environment. HHS will calculate
user fees owed, and issuers will remit the fee owed only once, in June of the year following the
benefit year, in connection with processing of payments and charges for risk adjustment.
We estimate that 1,800 issuers will be required to pay risk adjustment user fees, and the
additional cost associated with this requirement is the time and effort for an issuer to provide
monthly enrollment data and remit fees. Because HHS will utilize existing data collection and
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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

payments and charges processing, we do not anticipate that this provision will alter the collection
cost.
Under a distributed data approach, the required data is accessed and stored separately from
other issuer data pursuant to formats specified by HHS. We propose in §153.700(a) to require that
an issuer of a risk adjustment covered plan or a reinsurance-eligible plan in a State where HHS is
operating the risk adjustment or reinsurance program on behalf of the State, as applicable, must
provide HHS, through the dedicated data environment, access to enrollee-level plan enrollment
data, enrollee claims data, and enrollee encounter data as specified by HHS. We estimate that this
data submission requirement will affect 1,800 issuers, and will cost each issuer approximately
$342,086 in total labor costs. This cost estimate reflects the wages of 3 full-time equivalent
employees (5,760 hours per year) at an average hourly rate of $59.39 per hour for a technical
employee. We anticipate that 400 data processing servers will be established across the market in
2014 (at an average cost of $15,000) and issuers will process approximately 9 billion claims and
enrollment files in 2014. Therefore, we estimate an aggregate burden, including labor and capital
costs (as described in section 13 below), of $621,754,800 for all issuers as a result of these
requirements.
As described in 153.720(a), an issuer of a risk adjustment covered plan or reinsuranceeligible plan in a State in which HHS operates risk adjustment or reinsurance, as applicable, must
establish a unique masked enrollee identification number for each enrollee, in accordance with
HHS-defined requirements, and maintain the same masked enrollee identification number for an
enrollee across enrollments or plans within the issuer, within the State, during a benefit year.
Under §153.720(b), an issuer of a risk adjustment covered plan or reinsurance-eligible plan in a
State in which HHS is operating the risk adjustment or reinsurance program, as applicable, may
not include an enrollee’s personally identifiable information in the masked enrollee identification
number or use the same masked enrollee identification number for different enrollees enrolled
with the issuer. As discussed in OMB Memorandum M-07-16, the term “personally identifiable
information” is a broadly used term across Federal agencies, and has been defined in the Office of
Management and Budget Memorandum M-07-16 (May 22, 2007).1
We estimate that 1,800 issuers will be affected by the requirement to maintain a masked
enrollee identification number for each enrollee. The cost of setting up a masked identity for each
enrollee would be the time and effort required to assign an identification number to each enrollee
and remove other identifying factors from the enrollee’s profile or claims information as submitted
to HHS. We estimate it would cost each issuer approximately $178 per year, based on three hours
of work by a technical analyst at $59.39 per hour. Therefore, we estimate an aggregate cost of

1

Visit the Office of Management and Budget website
(http://www.whitehouse.gov/sites/default/files/omb/memoranda/fy2007/m07-16.pdf) to learn about the memorandum.

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

$320,706 for all issuers to maintain a masked enrollee identification number.
As described in §153.630, we will require health insurance issuers to comply with data
validation activities as specified by HHS or States. The burden associated with this requirement is
the issuer’s time and effort to provide HHS with source claims, records, and enrollment
information to validate enrollee demographic information for initial and second validation audits,
and the issuer’s cost to employ an independent auditor to perform the initial validation audit on a
statistically valid sample of enrollees. We estimate that each issuer sample will consist of
approximately 300 enrollees, with approximately two-thirds of the sample consisting of enrollees
with HCCs. We also anticipate that this audit burden will affect about 1,800 issuers. Based on
Truven Health Analytics 2010 MarketScan® data, we have determined that for enrollees with
HCCs, the average number of HCCs to be reviewed by an auditor per enrollee is approximately
two. Additionally, based on HHS audit experience, we estimate that it may cost approximately
$180 ($90 per hour for 2 hours) for an auditor to review the medical record documentation for one
enrollee with roughly two HCCs. We expect that it may cost approximately $30 per enrollee ($90
per hour for 20 minutes) to validate demographic information for all enrollees in the audit sample,
totaling approximately $210 per enrollee with HCCs and $30 per enrollee with no HCCs. We
assume that an initial validation audit will be performed on 180,000 enrollees without HCCs, and
360,000 enrollees with HCCs. For 1,800 issuers, we anticipate that the total burden of conducting
initial validation audits will be $86.4 million.

Table 1 - Burden Estimates for Risk Adjustment Data Collection and Data Validation

Forms
Type of
Frequency Number of
Number of
Average
(if necessary) Respondent
and
Respondents Responses per
Burden
Duration
Respondent Hours per
Response

Total
Burden
Hours

Risk adjustment
and reinsurance
distributed data
collection

Issuer

Annually,
Permanent

1,800

5,000,000

0.001

10,368,000

Masked
enrollee
information

Issuer

Annually,
Permanent

1,800

1

3

5,400

1,800

300

1.78

960,000

Risk adjustment
data validation
Total

Issuer

Annually,
Permanent

1,800

11,333,400

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Table 2 - Burden Estimates for Risk Adjustment Data Collection and Data Validation by Labor
Category

Type of
Respondent

Hourly Labor
Cost of
Reporting ($)

Total
Burden
Hours

Average
Labor Cost
per
Response

Technical Analyst

$59.39

10,373,400

$178

1,800

$616,075,506

Auditor

$90.00

960,000

$160

1,800

$86,400,000

1,800

$702,165,960

Total

9,981,348

Number of Total Labor Costs
Respondents (All Respondents)

13. Capital Costs
Regardless of the data format and specifications for the reinsurance and risk adjustment
programs, issuers will need to extract and, for purposes of audit, store the necessary data elements
separately from data used during the normal course of business. We anticipate that approximately
400 data processing servers will be established across the market in 2014 to process the required
data elements at an average one-time cost of $15,000 each. Therefore, we estimate a total capital
burden of $6,000,000 for all issuers subject to this requirement. This estimate does not include the
labor costs associated with data and server maintenance, which are estimated separately.
14. Cost to Federal Government
The initial burden to the Federal Government for the establishment of the risk-related
programs is $274,936. The calculations for CCIIO employees’ hourly salary was obtained from the
OPM website: http://www.opm.gov/oca/10tables/html/dcb_h.asp.

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Table 3 – Administrative Burden Costs for the Federal Government Associated with the
Reinsurance, Risk Adjustment, and Risk Corridors Programs

Task

Estimated Cost

Development of HHS notice of benefit and payment parameters
15 GS-13: 15 x $42.66 x 160 hours

$102,384

Technical Assistance to States
15 GS-13: 15 x $42.66 x 240 hours

$153,576

Managerial Review and Oversight
2 GS-15: 2 x $59.30 x 160 hours

$18,976

Cost of Contracts for HHS-operated Reinsurance and Risk
Adjustment
Total Costs to Government

$20,000,000
$20,274,936

15. Explanation for Program Changes or Adjustments
As detailed above, certain burden estimates for information collection requirements associated
with the reinsurance, risk adjustment, and risk corridors programs have changed from what
was previously estimated in the Premium Stabilization Rule due to policy changes in the final
HHS notice of benefit and payment parameters for 2014. We have also updated the burden we
described in the draft Payment Notice information collection notice published as part of the
proposed Notice of Benefit and Payment Parameters for 2014 (77 FR 73117) to reflect—
• policy changes that were finalized in the final HHS notice of benefit and payment
parameters for 2014,
• the agency’s most current estimates of the reinsurance, risk adjustment, and risk corridors
operations, and
• public comments on the information collection that were received during the 60-day
comment period.
As a result of these adjustments, we are reducing the total annual burden estimate described in
draft Payment Notice information collection notice by 9,741,696 hours, which results in an
estimated total annual burden of 1,013,293 hours associated with the requirements set forth in
the final HHS notice of benefit and payment parameters for 2014. This reduction reflects the
following modifications—
• an adjustment to our estimate of the burden associated with the distributed data
requirements under §153.610 and §153.700 to reflect only the incremental burden that was
not already accounted for in the information collection for the Premium Stabilization Rule,
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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment
•
•
•

addition of the burden associated with submission of a masked enrollee ID number under
the distributed data approach set forth in §153.610 and §153.700,
the removal of the burden associated with State operation of the risk adjustment and
reinsurance programs because we expect fewer than 10 states to operate risk adjustment or
reinsurance in the 2014 benefit year, and
an increase in the number of reinsurance contributing entities based on the Department of
Labor’s current estimate of the number of self-insured plans.

16. Publication/Tabulation Dates
The following information described in part 12 of this document will be published annually in
the HHS notice of benefit and payment parameters:
•
•
•

Approved State alternate risk adjustment methodologies (as described in §153.330).
States publishing a State notice of benefit and payment parameters described in §153.100110 will include the following annually in that notice, as applicable. The risk adjustment
methodology that will be used if the State is operating the risk adjustment program.
The data validation standards, as described in §153.350, that will be used when operating
the risk adjustment program.

Finally, States will publish information about their risk adjustment program in an annual summary
report to be submitted to HHS. HHS intends that these reports will be made public soon after they
are submitted.2
17. Expiration Date
Not applicable.
18. Certification Statement
There is no exception to the certification statement identified in Item 19, "Certification for
Paperwork Reduction Act Submissions," of OMB Form 83-I.

2 For 2014, two states have elected to operate reinsurance and only one state, Massachusetts, will operate risk
adjustment. The number does not reach the required threshold of nine or more entities affected and, therefore, we are
not submitting a PRA package. We will seek OMB approval in subsequent years if nine or more states decide to
operate risk adjustment programs.

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Appendix A
Data Category
Geographic Data

Market Level Data

Enrollee level data

Data Elements for Risk Adjustment and Reinsurance
Data Elements
Submitting Entity
• Metal level
• Actuarial value
• Benefit year
• Individual versus small-group
• State average actuarial risk (HHS-sourced)
• State Rating Curve
Includes header, issuer, and enrollee data elements:
• File ID
• Execution Zone
• Run Date
• Report Type
• Total Number of Enrollee Records
• Total Number of Enrollment Periods
• Record ID
• Issuer ID
• De-Identified (Masked) Enrollee ID
• Enrollee DOB
• Enrollee Gender
• Enrollment Period Activity
• Subscriber Indicator
• Subscriber ID
• Plan ID
• Enrollment start date
• Enrollment end date
• Premium Amount
• Geographic Rating area
• Interface Control Release Number

State

State

Issuers

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Data Category

Pharmacy Claims

Data Elements

Submitting Entity

Includes header, issuer, plan and claim data elements:
• File ID
• Execution Zone
• Run Date
• Report Type
• Total Claims
• Total Plan Paid Amount
• Issuer ID
• Record ID
• Plan ID
• De-Identified (Masked) Enrollee ID
• Claim ID
• Claim Processed Date/Time
• Fill Date
• Paid Date
• Prescription/Service Reference Number
• Product/Service ID
• Dispensing Provider Service ID Qualifier
• Dispensing Provider Service ID
• Fill Number
• Dispensing Status
• Void/Replace Indicator
• Total Allowed Cost
• Derived Amount Indicator
• Interface Control Release Number
• Plan Paid Amount

Pharmacy Claims

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Data Category

Medical Claims

Data Elements

Submitting Entity

Includes header, issuer, plan and claim header and claim
line data elements:
• File ID
• Execution Zone
• Run Date
• Report Type
• Total Claims
• Total Claim Lines
• Total Plan Paid Amount
• Record ID
• Issuer ID
• Plan ID
• De-Identified (Masked) Enrollee ID
• Interface Control Release Number
Claim Header Level Data Elements
• Form Type
• Claim ID
• Original Claim ID
• Claim Processed Date/Time
• Bill type
• Date Paid
• Void/Replace Indicator
• Discharge Status Code
• Statement Covers From
• Statement Covers Through
• Billing Provider ID Qualifier
• Billing Provider ID
• Total Amount Allowed
• Total Amount Paid
• Derived Amount Indicator
• Diagnosis Code Qualifier
• Diagnosis Code

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Supporting Statement For Paperwork Reduction Act Submissions: Standards
Related to Reinsurance, Risk Corridors, and Risk Adjustment

Data Category

Medical Claims
(continued)

Data Elements

Submitting Entity

Claim Line Level Data Elements
• Record ID
• Claim Line Sequence Number
• Date of Service - From
• Date of Service - To
• Revenue Code
• Service Code Qualifier
• Service Code
• Service Code Modifier
• Place of Service
• Rendering Provider ID Qualifier
• Rendering Provider ID
• Amount Allowed
• Amount Paid
• Derived Amount Indicator

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